Retrograde Transpedal Access for Revascularization of Below-the-Knee Arteries in Patients with Critical Limb Ischemia after an Unsuccessful Antegrade Transfemoral Approach

Abstract

Purpose: To evaluate the safety and technical and clinical success of endovascular below-the-knee (BTK) artery revascularization by a retrograde transpedal access.

Materials and Methods: We retrospectively identified 16/172 patients (9.3 %) with endovascular BTK revascularization in whom a transfemoral approach had failed and transpedal access had been attempted. The dorsal pedal (n = 13) or posterior tibial (n = 3) artery was accessed using a dedicated access set and ultrasound guidance. The procedure was finished in antegrade fashion by plain old balloon angioplasty (POBA). Comorbidities, vessel diameter and calcification at the access site were recorded. The analyzed outcomes were technical success, procedural complications, procedure time, crossing (guidewire beyond lesion and intra-luminal) and procedural (residual stenosis < 30 % after POBA) success, and limb salvage.

Results: Diabetes, coronary artery disease and hypertension were present in 15 patients (93.8 %), and both renal impairment and previous amputations in 7 (43.8 %). Pedal access vessel calcification was present in 5/16 patients (31.3 %). The mean diameter was 1.75 +/-0.24 mm. The procedure time was 92.4 +/-23 min. The success rate for achieving retrograde access was 100 %. Retrograde crossing was successful in 12/16 patients (75.0 %). Procedural success was observed in 10/16 patients (68.8 %). Minor complications occurred in 2/16 patients (12.5 %). The rate of limb salvage was 72.9 %, and the overall survival was 100 % at 12 months. Major amputations after revascularization occurred in 2/16 patients (12.5 %).

Conclusion: If an antegrade transfemoral approach to BTK lesions fails, a retrograde transpedal approach may nevertheless facilitate treatment. This approach appears to be safe and offers high technical and acceptable clinical success rates.

Key Points:

• Retrograde approaches via transpedal or transtibial vessels are safe and offer high technical success.

• One problem after technically successful puncture might be the re-entry following subintimal retrograde lesion crossing.

• After a failed attempt at antegrade revascularization of a BTK occlusion, a retrograde approach should be performed.

Citation Format:

• Goltz JP, Planert M, Horn M et al. Retrograde Transpedal Access for Revascularization of Below-the-Knee Arteries in Patients with Critical Limb Ischemia after an Unsuccessful Antegrade Transfemoral Approach. Fortschr Röntgenstr 2016; 188: 940 – 948

Zusammenfassung

Ziel: Evaluation der Sicherheit sowie technischem und klinischem Erfolg der endovaskulären Revaskularisierung kruraler Gefäßokklusionen über einen retrograd transpedalen Zugang.

Material und Methoden: Retrospektiv wurden 172 Patienten mit einer Unterschenkelrevaskularisierung zwischen 2/2014 und 8/2015 identifiziert. Bei 16/172 Patienten (9,3 %) war ein transfemoraler Rekanalisierungsversuch gescheitert und ein retrograd transpedaler Zugang unternommen worden. Unter sonografischer Führung wurden die A. dorsalis pedis (n = 13) oder die A. tibialis posterior unter Verwendung eines speziellen Sets punktiert. Die Prozedur wurde durch eine antegrade PTA beendet. Analysiert wurden Komorbiditäten sowie der Gefäßdurchmesser und -kalzifizierungsgrad des punktierten Gefäßes. Endpunkte waren technischer und prozeduraler Erfolg, periprozedurale Komplikationen, Prozedurzeit und Extremitätenerhalt.

Ergebnisse: Bei 15 Patienten (93,8 %) fanden sich jeweils Diabetes, KHK und Hypertonie unter den Komorbiditäten. Nierenfunktionseinschränkungen und stattgehabte Amputation fanden sich bei 7 Patienten (43,8 %). Bei 5/16 Patienten (31,3 %) bestand eine Kalzifizierung des punktierten Gefäßen, der mittlere Durchmesser betrug 1,75 +/-0,24 mm. Die Prozedurdauer betrug 92,4 +/-23 min. Der technische Erfolg betrug 100 %. Die retrograde Läsionspassage war bei 12/16 Patienten (75,0 %), die Gesamtprozedur bei 10/16 Patienten (68,8 %) erfolgreich. Minorkomplikationen kamen bei 2/16 Patienten (12,5 %) vor. Der Extremitätenerhalt, bzw. Überlebensrate nach 12 Monaten betrugen 72,9 % und 100 %. Majoramputationen nach der Revaskularisierung wurden bei 2/16 Patienten (12,5 %) durchgeführt.

Schlussfolgerung: Nach gescheitertem antegraden Revaskularisierungsversuch kann ein retrograd transpedaler Zugang den Prozedurerfolg ermöglichen. Die retrograde Punktion erscheint sicher und mit hoher technischer und akzeptabler klinischer Erfolgsrate vergesellschaftet zu sein.

Kernaussagen:

• Retrograd transpedale Gefäßzugänge erscheinen sicher und mit hoher technischer Erfolgsrate nutzbar zu sein

• Nach technisch erfolgreicher retrograder Punktion kann bei subintimaler Läsionpassage das Reentry problematisch sein

• Nach gescheitertem antegraden Revaskularisierungsversuch verspricht die retrograde transpedale Punktion Erfolg

Key words

CLI - pedal access - limb salvage - retrograde - endovascular

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